There is a wealth of evidence now that optometrists can be effective primary care clinicians, working independently or as part of managed clinical networks.
Acute eye management services such as the Primary Eyecare Acute Referral Scheme (PEARS) have been audited and show that accredited optometrists can effectively reduce the burden on over-worked ophthalmology departments.1,2,3 Glaucoma co-management schemes, likewise, have been found to be effective and were preferred by patients who valued the convenience.4,5,6
Regardless, Addie et al7 report that, while clinical and patient satisfaction standards were high, optometry services were found to be less cost effective. This seems to reflect a general view within our profession.
So are we undervalued by practice based commissioning (PBC) groups and the hospital eye service when LOCs negotiate shared care fees?
I certainly thought that many years ago while on a working group striving to organise a screening service for diabetic retinopathy. When, in my naivety, I pointed out to the diabetologist lead that an eye examination costs in the region of £50 to do and that a fee of £18.00 for screening was not viable I was told by her: 'I'm sorry Peter but we do not intend to pay for your fish tank'.
Like most optometrists I was so mentally locked into the quantum unit that was an eye exam with refraction and resulting in the sale of an optical appliance, that I could not initially comprehend what she was saying to me. Fundamentally our business plans are geared around huge floor spaces with huge staff levels to enable us to engage in the retail end of our professional duties. When negotiating a clinical service these overheads are of no concern to the would-be service purchaser. The costs that are of concern for an individualised budget for a specific service are the pro-rata use of the room and technology as well as the costs of staff time specifically utilised for the service provision. When budgeting using this criteria the final fees are far more cost effective for service purchasers and financially viable for the supplier.
Let us look at a new business plan, rather than trying to modify a traditional, primarily retailing strategy. A practice geared only to clinical practice requires two rooms, one for the optometrist and another for auxiliary tests of fields and photography. The reception area needs to have a seating area but no retailing floor space. Two colleagues are required, one to meet and greet, the other to carry out the auxiliary tests. The glaucoma co-management scheme being discussed currently in Northumberland is budgeted at £45 per appointment.
If the books were full, 15 patients per day, five days a week, 46 weeks per year this gives a turn-over of £155,250 (see the table below).
This leaves an annual take-home salary for me (remember there are no costs of sales) of £90,250. If perhaps 50 per cent of patients also legitimately required a GOS eye exam, comfortably accommodated in that half hour, I could expect to augment my salary by a further £34,000. Conversely, if my role is purely to monitor and treat glaucoma I could reasonably see three patients per hour the maths then predicts an annual turnover of £217,350.
Budgeting like this of course is not cost effective if you have a practice with every room fully occupied every day doing traditional refractions. In this case you would be swapping a more profitable use of the resources for a less profitable one. Unless you were very keen on pursuing clinical rewards and kudos, your choice would be simply - do not enter into a contract.
Any practice with spare capacity could consider this budgeting strategy. Separate out the proportioned running costs of the specific service. For instance the amount of rent that can be apportioned to the single room used and for the time it is used - remember no purchaser wants to support other business activities and sales oriented decor (the fish tank analogy) superfluous to the service provision.
Keen readers will have detected the flaw in my plan you will possibly only see two or three glaucoma patients per week. This inconvenient fact links to the second observation by someone outside optometry and therefore more objective. When discussing the incompatibility of HES and optometry budgeting as regards a stable glaucoma service an ophthalmologist specialising in glaucoma said: 'The fact is that we see glaucoma patients on an industrial scale'.
This refines the economic efficiency of the HES lead services significantly.
Unfortunately this is a fundamental truth. We can complain all we like about how we are undervalued and why we should not co-operate until we are paid legitimately as judged by our traditional and blinkered expectations, but the problem in budgeting is ours not theirs. While the HES or PCTs may pay slightly more for patient satisfaction, they could not rationalise a service with double the costs of their existing service.
If we want to forge ahead and become clinically valuable members of Managed Clinical Networks we need to become industrialised as well. To achieve this we may even have to carry some costs until service users and service financers become comfortable with new and largely untried suppliers.
Addie et al1 discussing the Scottish system, comment that while the financial infrastructure to manage many acute and chronic ocular conditions is in place, data collected from the GOS forms suggests that the take up is low. The authors point out that patients may be unaware that their optometrists can manage many conditions and also note that GPs are less likely to refer to optometrists.
This is an educational issue and needs to be addressed quickly if we are going to industrialise our clinical output.
I believe I have come close to achieving this in my private practice. The service plan involves a spare, floating optometrist, so our core business is not affected. Each individualised budget is calculated with the pro-rata strategy with no retailing costs inputted. While each individual scheme may not fill an optometrist's time, the inclusion of glaucoma management, low vision, acute presentations, diabetic retinopathy and the frequent walk-ins for traditional requirements keeps the optometrist financially viable and the practice maximises its industrialised capacity. Within Northumberland however, due to political and financial barriers, the glaucoma scheme never started while the acute eye management service and low vision service were abandoned. Regardless of these set-backs I am able to maintain the practice structure. This is largely due to the patient and GP educational processes that have been pro-actively nurtured over many years regardless of charging privately, we enjoy a regular flow of acute eye presentations, as walk-ins and via hospital and GP referrals.
Independent prescribing is potentially our profession's greatest opportunity since we were allowed to use diagnostic drugs. We must not fail future optometrists. Education gives us the theory and clinical practice, but we need to change our business concepts as well or we will simply price ourselves out of the market and all the education will be wasted. ?
References
For a full list of references email william.harvey@rbi.co.uk
? Peter Frampton studied optometry at QUT, Brisbane, Australia. Moving to Britain in 1986, he took ownership of Aaron Optometrists in Ashington, Northumberland, in 1993
